CLINICAL HANDBOOK OF SCHIZOPHRENIA

522 VII. POLICY, LEGAL, AND SOCIAL ISSUESsqualor or on the streets. Does such an apparently irrational choice necessarily imply alack of capacity, or must delusional reasoning be established? Even if capacity seems to beabsent, what minimum standard of living is in the best interests of a patient who expressesno desire for material comforts?Faced with such complex issues, it is tempting to resort to the traditional medical approachof assuming that best interests are best determined by a beneficent doctor. However,attempting to apply a capacity-based approach clarifies that the client’s reasoningabout his or her situation is the starting point for the decision, and makes it less likelythat the values, anxieties, or prejudices of others will prevail over the client’s expressedviews. Sharing difficult decisions with multidisciplinary teams, caregivers and advocatessimilarly reduces the risk of poor or hasty judgments.Though the law may allow compulsion on the grounds of risk to others, and mentalhealth services are exposed to strong societal expectations that they should prevent violenceby their patients, attempting to take an ethical approach to treatment pressure onthese grounds presents considerable difficulties. There are very few circumstances inwhich citizens without mental disorder can be detained preventively on the grounds ofrisk, and it is hard to justify taking a different approach to clients with capacity. The challengefor professionals is to avoid being pressured into applying an ethical double standard,in which behavior that would not justify significant sanction in the absence of mentaldisorder is used to justify loss of liberty, or in which levels of treatment pressure are notcommensurate with the actual level of risk.KEY POINTS• Involuntary commitment has historically been seen as a central aspect of the treatment ofschizophrenia.• Criteria for commitment vary between jurisdictions but typically include the presence of amental disorder, risk to the patient, risk to others, and an expectation of therapeutic benefit(or the prevention of deterioration).• These criteria are seldom capable of rigid definition, and their interpretation varies amongclinicians and jurisdictions, resulting in highly variable proportions of those diagnosed withschizophrenia being assumed to require commitment in different mental health systems.• The ethical basis of this is not always made explicit in law; therefore, clinicians must combinean understanding of the legal criteria for commitment with an ethical understanding ofthe basis for clinical involvement in state-sanctioned detention.• Good clinical practice requires the use of the least restrictive form of treatment.REFERENCES AND RECOMMENDED READINGSAllen, M., & Smith, V. F. (2001). Opening Pandora’s box: The practical and legal dangers of involuntaryoutpatient commitment. Psychiatric Services, 52, 343–346.Applebaum, P. (2001). Thinking carefully about outpatient commitment. Psychiatric Services, 52,347–350.Bindman, J., Tighe, J., Thornicroft, G., & Leese, M. (2002). Poverty, poor services, and compulsorypsychiatric admission in England. Social Psychiatry and Psychiatric Epidemiology, 37, 341–345.Holloway, F., Szmukler, G., & Sullivan, D. (2000). Involuntary outpatient treatment. Current Opinionin Psychiatry, 13, 689—692.Kisely, S., Campbell, L., & Preston, N. (2005). Compulsory community and involuntary outpatienttreatment for people with severe mental disorders. Cochrane Database Systematic Reviews, 3,CD004408.Kisely, S. R., Xiao, J., & Preston, N. J. (2004). Impact of compulsory community treatment on admis-